INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on July 31, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection and investigation LEF667011 Bridgeway House was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Therefore, deficiencies were identified during this inspection and a plan of correction is required.
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Plan of Correction
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§ 717.12 LICENSURE Refusal or revocation of license
§ 717.12. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the
Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the drug and alcohol recovery house.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or
attempting to obtain a license.
(6) Lending, borrowing or using the license of another drug and alcohol recovery house.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing residents at the drug and alcohol recovery house.
(9) Continued noncompliance in disregard of this part.
(10) Operating a drug and alcohol recovery house that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the applicant or licensee by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the drug and alcohol recovery house to correct deficiencies.
(c) If the drug and alcohol recovery house does not correct the deficiencies within the specified time, the Department will officially notify the applicant or licensee that it shall show cause why its license should not be denied or revoked under 1 Pa. Code § 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. The applicant or licensee shall file a written request within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code § 35.14.
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Observations
Based on an approved plan of correction that was submitted for the 2024 and the onsite license renewal for 2025, the recovery house failed to comply with a plan of correction approved by the Department, unless the Department approves and extension or modification of the plan of correction.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Director will review all previously approved Plans of Correction to ensure that each corrective action item is implemented as written and within the approved timeframe. The Facility Director will create a compliance tracking log that lists each POC item, its completion status, and the person responsible for the action. The House Manager will review this log monthly to verify progress and ensure any outstanding actions are addressed immediately. All staff involved in corrective actions will receive training on the importance of full adherence to approved POCs and the process for documenting completion. The Facility Director will provide oversight and submit any necessary extension or modification requests to the Department prior to deadlines.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance September 15th and will maintain ongoing monthly compliance reviews thereafter.
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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on review of the staff trainings the recovery house failed to have a mechanism to collect feedback on completed training.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Director will develop and implement a new, more comprehensive "Training Feedback Form" to replace the current version, ensuring it captures detailed input on training content, presenter effectiveness, and applicability to job duties. The House Manager will distribute the form immediately following all trainings, collect completed forms, and review them with the Facility Director to identify any areas for immediate improvement. The Facility Director will maintain all feedback forms on file for review during inspections and will oversee the process to ensure it is completed after every training.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain the improved feedback collection process for all future trainings. |
§ 717.18(c)(3) LICENSURE Training
§ 717.18. Training.
(c) In addition to training identified and provided under subsection (a), staff persons and volunteers shall complete the following within 90 days of becoming an employee or volunteer:
(3) HIV/AIDS, tuberculosis and sexually transmitted diseases training using a Department approved curriculum.
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Observations
Based on review of the staff trainings the recovery house failed to have sexually transmitted diseases training using a department approved curriculum completed within 90 days.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that all required trainings, including sexually transmitted diseases (STD) training using a Department-approved curriculum, are completed by all staff within 90 days of hire. The House Manager has been scheduled to complete the Department-approved STD training immediately, and verification of completion will be kept in the training file. The Facility Director will maintain a training tracker that lists all required trainings, due dates, and completion dates for each staff member. The tracker will be reviewed monthly by the Facility Director to ensure deadlines are met.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain timely completion of all required trainings for current and future staff. |
§ 717.22(b)(1) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(1) Disclosure to the resident of criteria for beginning and ending residency.
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Observations
Based on a review of resident records, the recovery house failed to have residents sign paperwork within 24 hours of arrival.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Director will update the intake procedure to require that all admission paperwork is completed and signed by residents within 24 hours of arrival. The House Manager will ensure that each resident completes all required forms during the intake process or, if arrival occurs after normal business hours, at the earliest possible time the following day. A checklist will be added to the intake packet to document completion of all required forms, and the House Manager will be responsible for confirming each item is signed before submission.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain timely completion of admission paperwork for all future residents.
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§ 717.23 LICENSURE Notification of decision to end residency
§ 717.23. Notification of decision to end residency.
(a) The licensee shall notify the resident in writing of a decision to end residency. The notice must include the reason and a timeframe for ending residency.
(b) The resident shall have an opportunity to request the licensee reconsider a decision to end residency before the decision to end residency takes effect.
(c) The resident may decide to end residency without providing a reason to the licensee.
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Observations
Based on a review of resident records, the recovery house failed to provide a written notification to the resident stating the decision to end residency in 6 unsuccessful resident records.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Director will revise the discharge procedure to ensure that all residents receive a written notification of the decision to end residency. The notification will include the reason for discharge, the effective date, and any appeal or grievance rights in accordance with facility policy. The House Manager will issue the written notification to the resident at the time of the discharge decision and will obtain the resident's signature acknowledging receipt. If the resident refuses to sign, the House Manager will document the refusal and retain a copy in the resident's record. The Facility Director will review all discharge files within 48 hours to verify that the written notification is present and complete before the file is closed.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will ensure that all future discharges include the required written notification.
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§ 717.27 LICENSURE Notification to family or emergency contact
§ 717.27. Notification to family member or emergency contact.
(a) The licensee shall develop and implement written policies and procedures that specify the methods and circumstances, including the resident ' s hospitalization or death, for notifying the resident ' s emergency contact with the resident ' s consent. The resident may revoke consent to provide notice to the emergency contact.
(b) The licensee shall make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (a) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected. This subsection shall not apply if the licensee knows or has reason to know of allegations of domestic abuse on the resident by the emergency contact.
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Observations
Based on a review of resident records, the recovery house failed to make at least one attempt to notify the resident ' s emergency contact in accordance with subsection (b) immediately and in no event more than 12 hours after the resident decides to end residency or does not return to the drug and alcohol recovery house as expected in 6 unsuccessful.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Director will ensure that the existing policy requiring emergency contact notification is fully enforced. The policy states that the House Manager must make at least one documented attempt to notify the resident's emergency contact within 12 hours when a resident decides to end residency or does not return as expected. If the initial attempt is unsuccessful, the House Manager must make a second documented attempt within one week of the first attempt. All attempts will be recorded in the resident's file with the date, time, method, and outcome. The Facility Director will review all applicable resident files within 48 hours of case closure to confirm that the required contact attempts were made and documented.
Person(s) Responsible: Facility Director, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain enforcement of the existing emergency contact notification policy for all applicable cases. |
§ 717.29(b)(1) LICENSURE Physical plant standards - Bldg-Exterior-Grnd
§ 717.29. Physical plant standards.
(b) Building interior, exterior and grounds. The licensee shall:
(1) Keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times.
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Observations
Based on a review of the physical plant inspection the recovery house failed to keep the interior, exterior, and grounds or yard of the drug and alcohol recovery house clean, safe, sanitary and in good repair and free of hazards at all times. There is multiple dresser drawers broken, wires hanging on back stairway, a hole in the wall with debris laying at the bottom of steps, landing at top of steps going to the bedrooms in the basement is a tripping hazard, and a uncovered light switch.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Owner will ensure that the interior, exterior, and grounds of the recovery house are maintained in a clean, safe, sanitary condition, free of hazards at all times. Immediate corrective actions will include repairing or replacing broken dresser drawers, securing or removing wires hanging on the back stairway, repairing the hole in the wall and removing debris at the bottom of the steps, correcting the tripping hazard on the landing leading to the basement bedrooms, and installing a cover on the exposed light switch. The Facility Owner will conduct a monthly walk-through of the property to identify and address maintenance or safety issues before they pose a hazard. Any identified issues will be repaired promptly.
Person(s) Responsible: Facility Owner, House Manager (to report any hazards immediately)
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain ongoing monthly inspections and prompt repairs.
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§ 717.29(e)(5) LICENSURE Physical plant standards - Bathrooms
§ 717.29. Physical plant standards.
(e) Bathrooms. The licensee shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a review of the physical plant inspection the recovery house failed to ventilate toilet and washrooms by exhaust fan or window which is a repeat citation for the bathroom on the first floor.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Owner will ensure that all toilet and washrooms are properly ventilated by an exhaust fan or window in compliance with facility requirements. For the first-floor bathroom, which has been cited previously, the Facility Owner will install a functioning exhaust fan or ensure the existing ventilation is repaired to meet standards The Facility Owner will conduct quarterly inspections of all bathrooms to confirm proper ventilation is maintained and will immediately address any deficiencies.
Person(s) Responsible: Facility Owner, House Manager (to report any ventilation issues immediately)
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain proper ventilation in all toilets and washrooms on an ongoing basis.
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§ 717.29(f)(4) LICENSURE Physical plant standards - Kitchens
§ 717.29. Physical plant standards.
(f) Kitchens. The licensee shall:
(4) Ensure that food items are stored off the floor.
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Observations
Based on a review of the physical plant inspection the recovery house failed to ensure that food items are stored off the floor.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The House Manager will ensure that all food items, including canned goods, are always stored off the floor in compliance with facility requirements. All canned goods currently stored on the floor have been relocated to appropriate shelving. The House Manager will conduct weekly checks of all food storage areas to confirm that no items are on the floor and will correct any violations immediately.
Person(s) Responsible: House Manager
Completion Date: The facility will be in full compliance by August 20, 2025, and will maintain proper food storage practices on an ongoing basis.
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§ 717.30(d)(2) LICENSURE Safety and emergency procedures -Extinguisher
§ 717.30. Safety and emergency procedures.
(d) Fire extinguishers. The licensee shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen in addition to the fire extinguishers required under paragraph (1) . The extinguisher in the kitchen must be located near an exit and away from the cooking area.
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Observations
Based on a review of the physical plant inspection the recovery house failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen in addition to the fire extinguishers required under paragraph (1) . The extinguisher in the kitchen must be located near an exit and away from the cooking area. This citation is a repeat.
These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
The Facility Owner will ensure that the kitchen contains a portable fire extinguisher with a minimum ABC rating, located near an exit and away from the cooking area, in addition to the extinguishers required under paragraph (1). The Facility Owner will purchase and install the appropriate fire extinguisher in the correct location. The House Manager will conduct monthly visual inspections to confirm that the extinguisher remains in place, unobstructed, and fully charged. Any issues identified will be reported to the Facility Owner immediately for correction.
Person(s) Responsible: Facility Owner, House Manager
Completion Date: The facility will be in full compliance by September 15, 2025, and will maintain compliance through ongoing monthly inspections.
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